suffering doesn't mean you are crazy

I don't want to dismiss or minimize anyone's suffering, but I don't like it when people call their suffering "Major Depression" or "Anxiety Disorder" when it isn't. Because I am vocal on the latter, sometimes people think I do want to deny or minimize other people's suffering.

It sucks to have your suffering minimized or dismissed. It's happened to me more than once that I have been miserable and people have dismissed it as not a big deal. I've been told to pull myself up by my bootstraps; I've been told that I just had a bad case of the growing ups; I've been told lots of insulting things. Telling me those things never made the suffering any less real or any less awful. You don't have to have Major Depression or an anxiety disorder to suffer. Suffering comes in lots of types and intensity, and just because someone doesn't have Major Depression doesn't mean they aren't suffering or that they are suffering any less. They are just suffering differently. (Okay, maybe there are a few people whose suffering I do want to minimize or dismiss, but they are a special case. These would be the people who feel they are entitled to a blissful existence without a blip of unhappiness.)

Still, it really steams me when people who do not have Major Depression (which I am using here only as an example, any other diagnosis could be substituted) are diagnosed with it or fish around for a diagnosis.

• I do not like it when people do this as a way to one-up each other in terms of "proving" their suffering. I may disagree with the concept of diagnosis, but I recognize that diagnoses exist for a reason and this abuses the concept of diagnosis.
  
• I do not like it when people are diagnosed with Major Depression, whether they asked for it or not, when they unambiguously do not fit the criteria. This also does violence to the concept of diagnosis. Major Depression is a tricky thing to study because (as I understand it) the studies done on it must operate under the assumption that Major Depression is a discrete thing, that all people with Major Depression have something, other than their symptoms and the "Major Depression" label, in common, even though we haven't identified it yet. I am not convinced of this assumption, but even so, adding more people to the mix, people who do not even fit the criteria, only confound the already questionable studies of Major Depression. Labeling extra people with Major Depression will water down the diagnosis (which I think is already watered down) and give both professionals and lay people a distorted understanding of Major Depression.
  
• I do not like that the diagnostic criteria for Major Depression is so wide as to include many normal life situations. Diagnoses are meant to identify pathology. Sometimes, people are sad. This is normal and healthy (and I know that "normal" does not equal "healthy") in many circumstances. The only life circumstance that the criteria specifically say to make sure you don't mistake for depression is bereavement, but people can be sad for longer than two weeks for other reasons and still not have a mental illness.
• I do not like it when people take labels of mental illness lightly. Mental illness is serious and having a label of mental illness has serious consequences. No, I do not think mental illness is something to be ashamed of or stigmatized. I'm not saying that I think it is inappropriate to joke about mental illness. But mental illness is not cool. If you do not have a mental illness, it is probably a bad idea to get yourself labeled with one (it can still be a bad idea to get labeled with mental illness even when it is legitimate). Many people have used the insanity plea to get out of jail sentences and regretted it when they succeeded. While most people will not spend years in forensic wards of a mental hospitals because they got themselves labeled with a mental illness they didn't have, they still may face unpleasant consequences as a result.

When people suffer, are not mentally ill, but are labeled with a mental illness, I am not going to deny their suffering. Even though they are not mentally ill, their suffering is still real. But I am not going to say it is okay for them to call it mental illness and I do not believe that denying that they are mentally ill equates to denying that they are suffering.

If you don't tell us, we don't know

I've kind of made a lot of accusations of mental health care professionals. I say kind of because, when I'm being diligent and conscientious, I leave an out. That out usually comes in the form of admitting that maybe I only think the professionals are acting cruelly because I am missing information. I don't have that information that might make me aware of professionals' good intentions because, as a patient, they don't tell me.

Some of the time when I am tempted to assume that the professionals have malicious motives, I have been able to think up reasons for why they might do exactly the same thing with benign motives, sometimes I didn't think of benign motives until later, sometimes I never thought of benign motives, but I have always been able to think up malicious motives. Malicious motives are easy to think up because so many of them are easy to apply to any situation: the professionals did that because they are jerks, because they want to confuse me, because they want to frustrate me, because they are drunk with power. Benign motives can be more difficult to think up because they seem to require being specific to the situation more often: they told me happy lies because they want to give me hope (even though it didn't work), they crushed my chest while restraining me because they want to keep me safe, etc.

This happened a lot in my experience of mental health care. When professionals taught me communication skills and then weren't receptive to me when I tried to use those very communication skills, I was tempted to assume they were just jerk hypocrites. The benign motive might have been that they were busy and forgot to follow up with me, that they simply didn't hear me, that they were still in the process of finding me an answer, or something entirely different. When I was at one hospital that said I should handle my impulses to self-injure by snapping a rubber band on my wrist and I went to another hospital that absolutely prohibited snapping a rubber band to control impulses to self-injure, I was tempted to conclude that both hospitals were full of crap and made up arbitrary rules. The truth might have been that both tactics are comparably effective, but that only one tactic can be used at a time and the two hospitals happen to have chosen different tactics.

My point here is that, no matter what a mental health care professional's reason is for doing these things, it is experienced by the patient in the same way. The patient will experience those happy hopeful lies the same way whether the professional is telling them with the goal of fostering hope or with the goal of eventual disappointment. Keeping this in mind, there are a lot of things to be paranoid about in mental health care. For professionals, it might not seem that way because they know what is going on and what their motivations are and that they are not telling lies with the goal of eventual disappointment. Patients, however, do not know what is going on behind the scenes, they do not know whether the professionals have good intentions; they only know that the professionals are doing frustrating or confusing things and that the professionals refuse to talk to them about that (and it is a pretty common assumption that they wouldn't hide it unless it was nefarious). Mental health care professionals sometimes end up suffering, too, with low morale from the unpleasantness of being hated by their patients.

There is a way for mental health care professionals to avoid most of this: to avoid letting patients assume that they have malicious motives, to avoid much of the paranoia patients have because of this, to avoid patients hating professionals on the basis of these untrue assumptions, to avoid the drudge of working with patients who hate you. EXPLAIN THINGS! Explain these things to patients who ask you, who directly challenge you about these things. Explain things to patients who might not be asking these things when it won't hurt anything to do so (because they still might be making assumptions and getting frustrated). There were only a couple of situations like this where thing were explained to me after I was frustrated and had made the assumption of maliciousness, and in those situations I was instantly calmed by the explanation. That won't happen every time, but it definitely won't happen if you don't bother to explain your benign motives.

I'm pretty sure that explaining things is a good idea. It's win-win. Patients get less frustration; professionals get a more pleasant work environment. I don't see any reason not to explain things. Unless you really do have something to hide...

I CHOSE ANOREXIA

I feel like shouting that from the rooftops. I CHOSE ANOREXIA. I knew what I was doing.

I was 17, driving South on County Farm Road, maybe to the ice rink or maybe to church. It was February or March. I was depressed, I had been depressed since I was 14 and it was driving me crazy. When I was 14 I needed a way to explain the depression to myself so I decided it was my punishment for being an awful horrible person. I had to convince myself that I was an awful horrible person and I did. By the time I was 17 I was desperate for relief; my depression was explained, which helped, but I was still going crazy from it. I thought the same things all the time, "I'm so depressed, it's because I'm so awful, I'm being punished, I need to be less awful." I became a perfectionist, I freaked out every time I fell on a jump while skating, every time I got a less than perfect score in school, every time I had a less than charitable thought. But I couldn't really become any less awful. There was kind of room for improvement, I could have given the right answer on the test or I could have landed the jump. On a literal level, I could have been doing better, but on a practical level, I couldn't. On a practical level, I was already doing phenomenally well at all of these things for someone who was losing her mind.

That day, when I was driving South, I thought about anorexia. I figured it would be easy, I was already fairly slim, enough that people had asked before if I was anorexic. I figured it would give me some new things to obsess about: I could think about food, calories, and the not eating of them. It would give me something less circular to think about; I could make a goal and reach it. It didn't matter so much to me what that goal was as long as it gave me a linear process instead of my circular, repetitive thoughts. It gave me a way to punish myself for not being perfect and a new way to become perfect.

I knew what I was getting myself into. I had seen the after-school specials, read the textbook in health class. I knew I was going to become a new kind of crazy. I knew that I would be obsessing over body image, which I never had before. But that new kind of crazy was part of the plan. Anything sounded better than the old kind of crazy. I weighed the pros and cons, but it was a pretty straightforward decision to me, since even the cons sounded so much better than my current life at the time. I chose anorexia.

But according to the professionals, no one chooses anorexia. I'm not sure why they like to say that so much. Maybe it is because they want to think of their patients as victims. Maybe because it helps people feel more charitable toward anorexics. I don't doubt that a lot of people become anorexic by accident. They go on a diet for whatever reason and they go too far and it becomes an obsession. They chose to diet but they didn't choose to become anorexic. That happens. But that isn't always how anorexia starts.

There are a lot of stereotypes about anorexia. It afflicts teenagers, girls, Caucasians, the middle and upper classes, perfectionists, smart people, etc. The professionals acknowledge these things, know that even if these populations are overrepresented among anorexics, but they also know that not every anorexic fits within these stereotypes (well, mostly). But I have heard a lot of professionals say that no one chooses anorexia and I have never heard anyone but myself say otherwise. Maybe I am the only person in the whole world that ever chose anorexia and these people just don't know about me. But I doubt that. Even if that was the case, why do professionals seem so confident in making that statement? So often, professionals tell their patients that everyone is different, everyone's anorexia is different, and every recovery is different, but then they say, "no one chooses anorexia," they think everyone is the same in that way. This attitude is so ubiquitous, I want to shout from the rooftops, "I CHOSE ANOREXIA," tell them they are wrong.

There are lots of generalizations like this made by mental health care professionals, who should know better. This is just one of them. But every generalization like this is impacting some patient somewhere in a negative way. When I had an intake interview for a treatment program, they asked how my eating disorder started and I told them. They refused to believe me, asked where I had heard of anorexia (Seriously? You expect me to remember? that is like asking me when I first learned what the word "the" meant.), asked if I had been teased, asked if someone suggested I go on a diet. That disbelief haunted my treatment. The professionals were so certain that I was hiding something, that something else had thrown me into anorexia, and they kept hounding me to talk about that thing, which didn't exist, so they neglected helping me with some of the things that did exist.

How do suicidal people talk about suicide?

Something that I have heard relatively frequently is that people who really want to commit suicide won't tell anyone about it and that anyone who tells another person about their desire to commit suicide doesn't really mean it. I guess this sounds good and maybe it even sounds like it makes some sense, but, to me, this doesn't make sense and basically amounts to blaming the victim, who is suicidal and probably already suffering enough.

(Note: I don't doubt that some people would tell someone of their plans to commit suicide because they are ambivalent about it or want that person to talk them out of it. It is the assumption that everyone who tells someone about their plans to commit suicide is ambivalent that I take issue with. I also don't doubt that there are people who talk about their desire to commit suicide who do so in a manipulative way to get attention, but I take issue with assumption that everyone who talks about their desire to commit suicide is doing so in a manipulative way.)

Obviously it is going to be easier to commit suicide if you don't tell anyone because you won't run the risk of being locked-up. I'm guessing that fact is the primary basis for this misconception. But what about other situations? If I want to rob a bank, this logic says that if I really intend to rob that bank, I won't tell anyone because that might compromise my ability to actually rob that bank. I've never heard anyone question the potential robber's intent to rob a bank on the basis that he told someone about it in advance. We explain this by saying that the potential robber was stupid or that he misjudged his confidant or something else. Why does this "if you tell someone about your plan than you must not really mean it" logic apply to suicide but nothing else?

So why might someone who is genuinely suicidal, someone who genuinely believes that suicide is there best option and has no ambivalence about going through with it, tell someone else about this even though that might prevent them from committing suicide?

• They might want to soften the blow to their loved ones. Even though the suicidal person knows that they will cause their loved one's grief, they might try to mitigate that by warning them, explaining the deep extent of their suffering, or telling them that it isn't their fault.
• Many people, generally, alleviate stress by talking about things. If the suicide is not immediate, the suicidal person may talk about his plan in order to alleviate stress between then and the time of their planned suicide.
• The suicidal person may confide in someone about their plans, someone who they think will be understanding and sympathetic to his situation, yet who will not try to get him hospitalized. The suicidal person may be wrong about their chosen confidant.
• I'm sure there are as many different reason for this as there are people who have done it.

I have also frequently heard people who tell someone else about their intent to commit suicide said to be "playing a game." The first time I heard this I was already in the hospital and I was brusquely told, "this is not a place for playing games." I was very confused. I understood that "playing a game" meant being manipulative by doing things like saying I am suicidal just to get sympathy or attention. But I wasn't playing that game; I was genuinely seriously considering the merits of suicide. (Additionally, if you are going to lock up everyone who says they are suicidal while assuming that anyone who says they are suicidal is "playing a game," how can you say the hospital is not a place for playing games? The hospital is the place for playing games because you have just rounded up all of the game players.) The idea that all patients who say they are suicidal do so in order to manipulate people is just plain mean.

Even if a suicidal person is telling someone else about it because they are ambivalent about suicide, what is wrong with that? Isn't that precisely the best thing for them to be doing, if you believe all suicides should be prevented? How is it manipulative to say, "I'm considering suicide because my life is super awful for reasons for x, y, and z. Right now, that is looking like my best option for relieving my suffering, but if there were a way to relieve my suffering without dying, if there were a way to enjoy life again, I would consider it"? Most people who are actively considering suicide are not able to express their desire for help in such a level-headed way, but that doesn't mean that they are manipulative when they express their desire for help in a mixed-up desperate way. I think that mixed-up, desperate people often get interpreted as being manipulative because they are changing their minds so much that, even though they are being sincere, they seem duplicitous because most of the time when people contradict themselves like this, they are lying. (Reading my old journals from when I was depressed is embarrassing because I changed my mind so many times and thought I found the secrets to the universe so many times. There are a lot of things I did during that time that were extremely ill-advised and may have come off as rude or contradictory or grossly inappropriate, but I did all of those things completely sincerely. This was a product of adolescence, but also a product of being out of my mind desperate for an end to my depression and anxiety.)

I can understand that it might be very frustrating to work with people who are constantly contradicting themselves and changing their minds. I can understand that it might be hard to distinguish who is doing this sincerely and who is doing this because they cannot keep their lies straight. I can understand the temptation to paint them with a broad brush as all being manipulative liars because they are all equally frustrating. I can understand the difficulty of distinguishing these two groups from each other and the high stakes for mixing up the two groups. I cannot understand the refusal to acknowledge, or the simple lack of acknowledgment, that some of these people are being genuine, not manipulative, but are having such a hard time within themselves that they contradict themselves and change their minds incessantly. I cannot understand not trying to distinguish those who are sincere from those who are manipulative and instead treating them all equally brusquely as people who are manipulative.

This post is partially a response to a comment on Bruce's post "Christianity and Mental Illness Part Three".

Overcertainty

I've been reading Jerome Bruner's Actual Minds, Possible Worlds (1986). I'm reading it primarily for my essay on recovery from eating disorders, as research on how reality gets translated into the stories that we tell about reality. In this book, Bruner mentions a study by Carol Feldman that examined the difference in how teachers speak to their students and how they speak to their colleagues. By measuring the frequency that teachers used words that indicate uncertainty (i.e. might, should, etc.) with their students and with their colleagues, Feldman found that teachers presented their students with a "far more settled, far less hypothetical, far less negotiary world than the one they were offering to their colleagues" (Bruner, 126).

I've been wondering for a long time how mental health care professionals, people who genuinely want to help their patients, can hurt them so much. I think that part of the explanation is a sort of blindness among professionals. I posited in my undergraduate thesis that part of this might come from goal displacement. (In goal displacement a goal is defined and a procedure is established with the aim of accomplishing that goal. Later the procedure becomes the de facto goal. Sometimes this means that the original goal is subverted because the procedure has become inflexible and cannot allow for special circumstances by examining whether or not the procedure will be able to accomplish the original goal.) After reading this discussion by Bruner, I wonder if this professional blindness also comes from an education that presents our knowledge of mental health and mental health care as being more settled than it actually is.

While it is appropriate to present the world as very certain and settled to elementary school children, I think this is entirely inappropriate at the college level. At Shimer College, the world definitely came across as being very uncertain, but I know that many colleges present the world as being very certain and settled. I wish it were reasonable to assume that all college students should already understand that the world is not as certain as high school history textbooks present it, but I know better than that. Taking those two factors into account, I can see how people might graduate college, even earn a graduate degree and go on to practice as a mental health care professional, still believing that everything they were told in their psychology classes is hard fact. I have had some very confusing interactions with professionals that this would explain very well.

I'm imagining it like this: A student goes through school and graduates high school never having been told or having considered on her own that things aren't as straightforward as textbooks and teachers have presented to her. She goes to college and majors in psychology. In her classes things are still presented as being very certain; she is comfortable with this and accepts it at face value. She graduates still thinking everything she has been taught has been determined quite certainly. She goes to graduate school and still accepts things that way. She gets a job in mental health care and interacts with patients based on this certainty. When patients doubt the science behind psychotropic medication, she dismisses them. When patients explain the genesis of their illnesses and this doesn't fit in with any of the schema she was taught, she dismisses them. When patients express any of the questions of the sort that she neglected to consider as a student, she dismisses them. Perhaps she goes on to teach the next generation of mental health care professionals. Because she never questioned the certainty of our knowledge of mental health and mental health care, she cannot encourage her students to do so and she cannot engage in discussion with her students even when they do question this certainty.

I understand presenting things as though they are straightforward in college classes. I would call this a shortcut. It would be very inconvenient and cumbersome so have to qualify everything you say in a lecture with, "this is just a theory and there may be other valid explanations." If you had a class full of students that you knew were able to fill in those qualifications without your making them explicit, it would be marginally okay not to make it explicit, but it would still be better to remind them occasionally of the uncertainty and explore with them some of the other possible explanations. If you don't bother to make the uncertainty explicit in a class where not every student is reliably able to keep that uncertainty in mind, you are doing those students and their future patients a serious disservice.

I imagine that in a lot of professions, things are presented as being very straightforward in school, but when the students begin their careers or go on internships, their experience reliably teaches them that things are not as certain as they appeared in school. I still think this uncertainty and plausible alternatives should be addressed in school, but in this case that is not as critical. In the mental health care profession, some of the illusions of certainty may be dissolved once a student begins practicing, but many may still remain. Patients like me may directly challenge a professional's, or intern's, certainty by asking pointed questions or patients may challenge a professional's certainty indirectly by simply being different and having a different experience of mental illness than the professional was taught about. However, since these are patients challenging the certainty of the professionals and interns, that challenge is more likely to be dismissed, rather than seriously considered like it should be, than if the challenges came from someone else.

And just so it doesn't look like I am presenting things more straightforwardly than they actually are: I don't think this is a problem for every mental health care professional. I'm not even certain about any of this. But, based on what I have experienced in my interactions with mental health care professionals, this is a plausible explanation for the problems I have encountered.

psychiatric diagnosis is a cognitive shortcut

One of the "cons" of psychiatric diagnosis is that people forget they are using them as cognitive shortcuts. One way this happens is that the professionals take stock of a patient's symptoms, determine a diagnosis for the patient, and then use that diagnosis to communicate about the patient rather than using the original symptoms. I'm skeptical about the potential utility of this, but I do understand the use of cognitive shortcuts: we all use them and our brains would probably explode if we didn't. However, I think this is an area that warrants more conscientiousness than the use of diagnosis is able to provide. Yes, even referring to symptoms is a cognitive shortcut--putting things into language at all is a shortcut--but it is less of a shortcut and would rid mental health care of at least some of the problems that arise from speaking in terms of diagnosis.

Part of the problem in using diagnoses, rather than symptoms, to talk about patients' experiences is translational. Patients tell professionals their symptoms in their own words (i.e. "I can't have fun. I do things that used to be fun, but I just get bored."), the professionals translate that into their clinical way of describing symptoms (i.e. "markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day" - DSM-IV, Major Depressive Disorder ), then the professionals translate those symptoms into a diagnosis (i.e. Major Depressive Disorder). When it comes time to educate patients about their illnesses and engage them in treatment, the professionals have to translate those diagnoses back into symptoms; sometimes they express them in the vernaculars that the patients use and sometimes the professionals express them in their clinical language or in a vernacular foreign to the patient. This is like translating from English (patient symptom language) to Spanish (professional/clinical symptom language) to Swedish (diagnosis language), then back to Spanish, and maybe back to English, but maybe to an English with different idioms and slang (i.e. British English instead of American English). This leaves a lot of room for error, where things can't be translated very well because of the mismatch in vocabularies, and this leaves a lot of room for misunderstanding.

Another problem created by using diagnoses as a cognitive shortcut to understanding and communicating about patients is that there is a loss of specificity. Of course when one person reports something, anything, to another person, the second person will know much less about that topic than the first person; this phenomenon is not limited to mental health care. However, when the patient's report to the professional is translated to the clinical language of describing symptoms, more specificity is lost. When the clinical version of the patient's symptoms are translated into a diagnosis, a lot more specificity is lost. This can, and has, lead to an anorexic being treated for and repeatedly asked about her purging. This anorexic, me, never purged to begin with. Purging is not a necessary symptom for diagnosing Anorexia Nervosa, but it is a possible symptom. After I was diagnosed, however, all of the symptoms of Anorexia Nervosa were imputed on me by the professionals, whether or not I actually had them. When I was discharged from the hospital, my papers declared that I was not purging, which, while true, was irrelevant. Because the criteria for diagnosing mental illnesses often say things like, "Five (or more) of the following symptoms have been present," (DSM-IV, Major Depressive Disorder) someone can be diagnosed with an illness, yet not have all of the symptoms listed in the diagnostic criteria for that illness. This seems obvious, but it means that when someone is diagnosed with Anorexia Nervosa, for which purging is one of the possible diagnostic symptoms, the diagnosis of Anorexia Nervosa noes not imply that any particular patient necessarily purges. It is simple syllogistic logic--some anorexics purge, jessa is anorexic, therefore we still don't know whether or not jessa purges--but this logic isn't making its way to all the mental health care professionals on a level that will prevent them from making unwarranted assumptions like this.

Diagnosis also allows for extra layers of stereotypes. A professional can stereotype a patient without diagnosis--on the basis of their race, gender, symptoms, clothing, etc. However, clinical descriptions of symptoms and diagnoses give the professionals an extra basis for stereotyping their patients. The general public has stereotypes for various mental illnesses and I am confident that professionals do, too. Many of those stereotypes are derogatory, like the assumption that depressed people are just whiners. The negative consequences of derogatory stereotypes are probably obvious, but in the context of mental health care they can be more damaging than usual. Stereotypes don't have to be derogatory or even negative at all. There are lots of things that are "known" about Anorexia Nervosa that don't enter into the diagnostic criteria at all. Anorexics tend to be rich, white, teenagers, perfectionists, smart, driven, etc. None of those are part of the definition, the diagnostic criteria, of Anorexia Nervosa, but they tend to be imputed on patients as though they are part of the definition. These things that we "know" about anorexics may be things that tend to be common among anorexics. It is fine to recognize these trends, but when they become assumptions about individual patients, that is when they become problematic--professionals start insisting that patients work on particular issues in treatment that may or may not actually have any relevance for any particular patient.

Pros and Cons of Psychiatric Diagnosis

I happen to think that the use of psychiatric diagnosis does more harm than good. I'll tell you why. Please tell me what you think I've missed.

Pros

• Psychiatric diagnosis provides a framework within which to understand mental illness.
• By noticing which symptoms seem to show up together, then noticing which cluster of symptoms a particular patient seems to fall into, treatment decisions can be informed by what has or has not worked for other patients with similar clusters of symptoms.
• Diagnoses can serve as a sort of cognitive shortcut. Rather than list all of a patient's symptoms individually, professionals can name the cluster and understand the patient more quickly, speeding communication.
• When patients are given diagnoses, it can validate their experiences by letting them know that others have had similar experiences.

Cons

• When the incomplete and tentative nature of the framework for understanding provided by psychiatric diagnosis is not acknowledged or is forgotten, it is used rigidly and inappropriately. I think this is probably a good part of the cause of the other problems diagnosis can cause.
• Experience with patients having those clusters of symptoms, known as diagnoses, can appropriately be used to inform treatment, however, this tends to be used to dictate treatment.
• As a cognitive shortcut, diagnosis would be useful only if people were mindful of the fact that they are using it as a cognitive shortcut. When people lose that mindfulness, diagnosis becomes a stereotype.
• When diagnoses are overused, this harms those patients who validly fit the diagnosis. Services are taken up by people who don't need them as badly. The people who are inappropriately diagnosed give the diagnosis, and those who are appropriately diagnosed, a bad name and additional stigma in the eyes of the public (i.e. "depressives are just whiners.").
• The rampant co-morbidity of diagnoses makes the framework lose its usefulness as a tool for simplifying and may even make mental illness seem much more complex.

I think that psychiatric diagnosis has some potential to be useful and beneficial. However, I think that the way they are presently used negates and actively prevents the potential usefulness they have. I also don't think the potential benefits are worth all the energy that goes into creating and maintaining this framework of diagnoses, nor do I think that the benefits are worth even the risk of them being used as inappropriately as they are.

I would rather see symptom-based treatment. Symptoms could be used to identify what needs treatment for each patient rather than diagnoses. Patients would list the symptoms that bother them and receive treatment for those and their underlying causes. There would be no misdiagnosis. No one would be treated for symptoms they don't have, because there would be no reason to assume that a cluster of symptoms has to go together. Even when patients have symptoms that do tend to go together, but one doesn't bother them, professionals won't have to feel compelled to treat that irrelevant symptom in the interest of treating the "full illness".

I know insurance-wise this may create practical problems, but I see the GAF score as the only thing they really need to know in terms of approving benefits; anything else is just the insurance companies meddling. I have no problem with GAF scores; I think they do a much better job than diagnoses. I wish that GAF scores were given more attention than diagnoses.

I am a moderate on mental health care

I do not like the way mental health care is currently done. Because I criticize it, however, people sometimes want to lump me in with antipsychiatry and sometimes with the Scientologists. I read things by people who are virulently antipsychiatry and I do gain some semblance of comfort from it because it shows me that not everyone has been brainwashed into thinking mainstream mental health care is a good idea. However, I do have some of the same problems with antipsychiatry and other people who oppose mainstream mental health care as I do with mainstream mental health care itself.

I recently read an article by Ty Colbert in which he focuses on the shortsightedness of NAMI. He writes about how NAMI is comprised of parents who come together for support in caring for their mentally ill children, but how they are so invested in mainstream mental health care that they are blinded to alternative solutions and cures for their children's problems and illnesses. That is pretty much how I view NAMI . However, I do not agree with the alternative that Colbert proposes in his article--to focus exclusively on biographical issues as the cause of mental illness--any more than I agree with focusing exclusively on biochemical causes as NAMI does. I appreciate that Colbert wants to open up the discussion to include biographical causes, but I disagree with making it exclusive to biographical causes.

I haven't actually experienced mental health care that was either completely focused on biochemical causes or biographical causes, but rather, most of the mental health care has been focused exclusively on both. That might sound kind of confusing or dumb, and it is. In a lot of different mental health care settings I have had professionals try to absolve me of guilt for my mental illness by telling me that it wasn't my fault, it was just that my brain chemicals were messed up and, later, insist that there must have been some event or something that set off my depression.

There are a lot of different positions one can take between the "all therapy" approach and the "all drugs" approach and I don't expect consistency between mental health care settings, even though it is very confusing as a patient. Within a single setting, such as one unit in a psychiatric hospital, I would hope for consistency, but I can see how that would be difficult to manage, even though the lack of consistency is confusing to patients. However, I have experienced this lack of consistency even from individual mental health care professionals, which is a kind of confusing that I cannot understand and it is at this point that I begin to call this "dumb".

It isn't that I can't comprehend holding the theories of mental illness as biographically caused and as biochemically caused in tension, it is the way they they use these theories as interchangeable, each to be used whenever it is most convenient, that I don't understand. It is like how my brother calls me either his "big sister" (because I am older than him) or his "little sister" (because I am smaller than him); whichever is convenient to his argument at the moment. There is either a lack of integrity or a lack of thought going on here that is so extreme as to be incomprehensible to me. (I know that I very well may be doing the same thing in some other area such that it is incomprehensible to others, but that doesn't mean I'm not validly recognizing this here.)

There are also people who just don't believe that mental illness even exists. Some people think mental illness is largely a way to label and manage people who act in ways contrary to the cultural norm. Again, I do appreciate that people like this are opening up the discussion to the possibility that what is called "mental illness" might be better called "a little different from the rest of us", but I don't agree that this is a full explanation of the phenomenon of mental illness (or "mental illness") anymore than I think biographical or biochemical theories fully explain mental illness. I do agree that sometimes things are called mental illness when they shouldn't be, sometimes on an extreme level (drapetomania was the mental illness that caused slaves to run away, until slavery was no longer socially acceptable) and sometimes on a more subtle level (the fact that I refuse to do affirmations has always be assumed to be a symptom of my depression, though it isn't). I do not believe that all mental illness is just being different in socially unacceptable ways, but I do believe that sometimes it is and that once someone is labeled "mentally ill" many more of their socially unacceptable differences are treated as pathology than if they were not labeled as "mentally ill". If I was not mentally ill, I doubt anyone would care that I refuse to do affirmation or consider that indicative of mental illness, but because I have been labeled "mentally ill", my refusal to do affirmations is treated as a symptom of my mental illness.

I read a fictional story by Kevin Brockmeier that included the sentence, "People who read Tolstoy find it difficult to be alive because they are reasonable, while people who read Dostoyevsky find it difficult to be alive because they are not." I read both Tolstoy and Dostoyevsky. I know that part of why I found it difficult to be alive was because I was unreasonable in some ways, but part of the reason I found mental health care to be so intolerable was because I was still reasonable in other ways. My depression caused me to be unreasonable (or however you want to explain the link between depression and unreasonableness). However, I was still reasonable enough to know that it didn't make sense to explain mental illness as exclusively caused biographically, biochemically, or, paradoxically, exclusively both, and I was still reasonable enough to understand that a lot of other things about mental health care are also unreasonable.

Small Business

I want my little Made with Awesome shop to stay small. I have no intention of making it my full-time job, but I would hope to make a little money with it, of course. So! I have been researching how to set myself up legal-wise. I think I understand most of what I need to do: register with the county, register with the village, do a fictitious name registration, get a tax ID so I can get a business bank account (maybe? probably?), fill out schedule C on my yearly income taxes. I'm decently confused about sales tax collecting and "business" vs. "hobby" classifications. There are small business development centers and places where you can go talk to someone about your venture or get a mentor. I will probably go talk to one of those people; confirm what I do know and clarify what I don't.

I feel pretty dorky doing all this. Kind of like I'm pretending to be some big businesswoman or being unrealistically ambitious. I'm not even that ambitious about this, I just want to do it right and legal. I'll excuse myself by saying I work in a court law library, so I have to be extra legal. (Extra = "superlatively" not "outside")

Validation, part 3

Here I'm expanding on what I mentioned about the consequences of telling lie to patients before (here and here).

When a patient is paranoid, delusional, or hallucinating, part of the role of mental health care is to introduce the patient to reality. The invalidating aspects of mental health care can create problems in this area.

There are a lot of lies that get told in mental health care. When I've talked to some professionals, they deny telling lies and act horrified that I would say this. I'm not sure if these people genuinely don't tell lies (I have been mostly talking to the "cream of the crop") and genuinely don't see their colleagues telling lies. Perhaps they actually believe some of these lies (I suspect they do) and perhaps they think that some of these lies are innocent and protective. Perhaps (as the most nefarious of possibilities) they don't care not to lie because they figure that mental health care patients won't know the difference anyway.

Lying to patients doesn't only include intentional outright lies. It includes dismissing or confirming a patient's belief without stopping to reconsider your own bias on the subject. If a patient accuses one of your colleagues of something and you dismiss this instantly because it sounds out of character for your colleague, you may be inadvertently lying to your patient. If you have literally misunderstood a situation and you pass on your misunderstanding to your patient, you are lying to your patient. I know it would be hard to know when you have misunderstood something, but, just as self-awareness can greatly benefit patients, self-awareness of the fact that you can misunderstand situations and awareness of your own biases can go a long way for staff, too. I think you have to be more careful with confirming or denying the reality of things with your patients than you have to be with yourself. Unfortunately, the trend seems to be for professionals to be less careful with this for their patients than for themselves.

Part of introducing someone to reality is helping them discern which parts of their experience are real and which are imagined. If you lie to patients, this gets in the way of helping them meet reality. Those patients are still relying on you to introduce them to reality; they won't be able to tell when you are lying to them and when you aren't. When you tell them which things are and are not real, they are going to be looking for trends so that they will eventually be able to discern those things themselves. It is entirely reasonable to reject the things that patients say when they are wrong or off-base; that will help them meet reality. But if you lie to them about what is true, your lies may skew the trends they will use to build their own tools for discerning reality.

This wouldn't be as bad if patients who needed help discerning reality were going to rely on you for this forever; you would have complete control over what they determine to be reality. It is still cruel to manipulate their perception of reality, but the consequences might not get out of control. However, patients won't and can't rely on you forever, so lying to them sets a precedent. They will incorporate that lie into their attempts to create their own system for discerning truth from paranoia, delusions, or hallucinations. If you have lied to patients, they might end up identifying the wrong trends to help them separate truth from fiction. This means that, going forward, they are still mistaking a lot of truth for fiction and a lot of fiction for truth. Despite all this work, they will still have a cripplingly flawed reality-detector.

Not all patients are so out of touch with reality that they will need to devise an entire new system for recognizing reality. This is the kind of patient I have usually been. Still, as a patient, I have known that my perception of reality wasn't entirely accurate. I did know that most of my shortcomings in perceiving reality concerned the reality of myself. This meant that when I was lied to about the rules of the unit or social norms outside the hospital, I knew I was being lied to and it was frustrating, but it didn't change my perception of the reality of those things. However, when I was lied to about myself, when I was told I was manipulative and Borderline Personality Disordered, this really made me question my perceptions of myself. When I reflected on myself and my actions and was honestly unable to find Borderline-like-ness in myself, I was very confused and thought I must be in denial. I knew that I wasn't the best judge of myself, but I really didn't see myself fitting this diagnosis. Eventually, I managed to convince myself that I really was Borderline Personality Disordered by contriving past situations to fit with BPD. Later, I mentioned to a therapist that my Borderline-ness was something I wanted to change about myself, but that progressed by her returning me to the reality that I was never Borderline Personality Disordered to begin with. Even though this is not as extreme of a flawed-reality detector as a patient who comes into mental health care further removed from reality might end up with, it is definitely not helpful to one's mental health and is an example of a patient being worse off on account of mental health care.